1. Some skin conditions Ali Al Khader, M.D. Faculty of Medicine
Al-Balqa’ Applied University

3. Some skin conditions Acute Inflammatory Dermatoses
Chronic Inflammatory
Dermatoses
Blistering (Bullous)
Diseases
Disorders of Epidermal
Appendages
Panniculitis
-Urticaria
-Acute
eczematous dermatitis
-Erythema multiforme
-Lichen planus
-Psoriasis
Acne vulgaris
Inflammatory
blistering diseases
-Pemphigus vulgaris
-Bullous pemphigoid

4. Urticaria = “Hives” -Mast cell-dependent, IgE-dependent
-Mast cell-dependent, IgE-independent
-Mast cell-independent, IgE-independent
*Individual lesions develop and fade within hours (usually less than 24 hours), and episodes may last for days or persist for months.
*Pruritic edematous plaques called wheals
…any area exposed to pressure, such as the trunk, distal extremities, and ears
Persistent episodes…?? Collagen vascular diseases, Hodgkin…etc.
But most of the time: unknown cause

5. Urticaria, cont’d *Mast cell-dependent, IgE-dependent
-caused by many antigen types (pollens, foods, drugs, insect venom…etc.)
-an example of a localized immediate hypersensitivity (type I) reaction
*Mast cell-dependent, IgE-independent
-substances that directly incite the degranulation of mast cells
…such as opiates, certain antibiotics, curare, and radiographic contrast media
*Mast cell-independent, IgE-independent
-local factors that increase vascular permeability
…aspirin-induced urticaria
…hereditary angioedema

6. Eczema = Spongiotic dermatitis
allergic contact dermatitis
(2) atopic dermatitis
(3) drug-related eczematous dermatitis
(4) photoeczematous dermatitis
(5) primary irritant dermatitis
…in this case, laundry detergent in clothing
Edema within the epidermis (spongiosis) creates small fluid-filled intraepidermal vesicles
Acutely: erythematous vesicular rash
…with chronicity:
Parakeratosis, hyperkeratosis & acanthosis…scales
T cell-mediated inflammatory reactions (type IV hypersensitivity)

7. Erythema multiforme -herpes simplex…etc. -sulfonamides…etc. -cancer
…an example of “interface dermatitis”
…target-like lesions consist of a central blister or zone of epidermal necrosis surrounded by macular erythema
…lymphocytes accumulating along the dermoepidermal junction where basal keratinocytes have begun to become vacuolated (arrow)
Self-limited hypersensitivity reaction to certain infections and drugs
-herpes simplex…etc.
-sulfonamides…etc.
-cancer
-Collagen vascular diseases
…necrotic/apoptotic keratinocytes appear in the overlying epithelium (double arrow)

8. Lichen planus Koebner phenomenon is present here
Oral lichen is risky for oral squamous cell carcinoma

9. Psoriasis Auspitz sign??
…epidermal hyperplasia (acanthosis), parakeratotic scale, loss of granular cell layer and accumulation of neutrophils within the superficial epidermis (Munro microabscesses)
Salmon-colored lesions covered by silver-white scales
-Any age, more in hormonal changes (puberty & menopause, but improves in pregnancy)
-Autoimmune, multifactorial (genetic & environmental)
-Associated with other autoimmune diseases like DM 1
-Associated with psychiatric problems
-Association with metabolic syndrome, hyperlipidemia, obesity
& DM 2
-Of the factors: trauma, drugs, infection (e.g., pharyngeal
streptococcal infection & guttate psoriasis), strong sunlight,
stress, smoking and alcohol consumption
-Koebner phenomena
Psoriasis may be associated with AIDS

10. Psoriasis Clinical variants Pathogenesis:
…role of TNF-alpha, induces proliferation of keratinocytes (acanthosis)…rapid migration of keratinocytes into stratum
corneum (abnormal cornification)…parakeratosis (scales clinically)
…dendritic cells including Langerhans cells and T cells…activated T cells produce cytokines such as TNF-alpha
Clinical variants
1- Plaque-type psoriasis (= psoriasis vulgaris)…most common…previously described lesions with Auspitz sign
…most commonly elbows & knees…severe itching
2- Inverse psoriasis…no scales, skin folds (under breasts, armpits and near genitals…etc.)…may be induced by sweat & fungal growth
3- Acute guttate psoriasis…children, adolescents and young adults…around 2 weeks after beta-hemolytic streptococcal infection (tonsillitis/pharyngitis) or viral infection
…diffuse erythematous small drop-like lesions with fine scales
…usually self-limited in 3-4 months
4- Pustular psoriasis
…uncommon
…pustules (fluid-filled lesions)
…may be acute emergency requiring systemic therapy
5- Erythrodermic psoriasis…large area covered by erythema
…may also threaten life (anemia, heart failure…etc.)
6- Psoriatic diaper rash
…the most common type of psoriasis in children < 2 years
…not only diaper area

11. Psoriasis Psoriatic arthritis Nail involvement
-10-30% of psoriasis patients
-10-15% of psoriatic patients with arthritis, joint symptoms precede skin involvement
-Rarely, may occur without skin disease
Nail involvement
-Pitting: the most common…punched-out depressions
-Oil spots: fluid collections with yellow-brown discoloration
-Onycholysis (nail separation)
-Thickening and deformity

12. Pemphigus vulgaris
Suprabasal separation resulting in intraepidermal blister
Mucosal epithelium is also involved
Fishnet appearance on immunofluorescence
due to deposition of antibodies
4th-6th decade
Tombstone appearance of basal cells
…scalp, face, axilla, groin, trunk,
and points of pressure
…may present as oral ulcers that
may persist for months before skin
involvement appears
…bullae can rupture easily
…autoantibodies against desmoglein in
desmosome

13. Bullous pemphigoid Elderly patients Tense bullae
…all the epidermis is separated from the dermis
…the inner aspects of the thighs, flexor surfaces of the forearms, axillae, groin, and lower abdomen
Oral lesions are present in 10% to 15%
Immunofluorescence showing continuous linear pattern
at the dermoepidermal junction due to deposition of
the antibodies that attack hemidesmosomal components

14. Panniculitis Inflammatory reaction in the subcutaneous adipose tissue
…may preferentially affect
the lobules of fat (erythema induratum) or
(2) the connective tissue that separates fat into lobules (erythema nodosum)
…often involves the lower legs
Erythema nodosum is the most common form

15. Panniculitis, erythema nodosum
Tender papules
Caused by:
-Infections (β-hemolytic streptococcal infection, tuberculosis and, less commonly,
coccidioidomycosis, histoplasmosis, and leprosy)
-Drugs (sulfonamides, oral contraceptives)
-Sarcoidosis
-Inflammatory bowel disease
-Certain malignant neoplasms
-Many times a cause cannot be identified
Delayed hypersensitivity reaction to microbial or drug related antigens, may also immune complexes

16. Panniculitis, erythema induratum…uncommon
Primarily adolescents and menopausal women
Vasculitis of deep vessels supplying the fat lobules of the subcutis
Originally considered a hypersensitivity response to tuberculosis, but today most commonly occurs without an associated underlying disease

17. Acne vulgaris Middle to late teenage years
Both males and females…males more severe
Usually milder in people of Asian descent
…Risk factors:
*Drugs: corticosteroids, adrenocorticotropic hormone, testosterone, gonadotropins, contraceptives, trimethadione, iodides, and bromides
*Occupational exposures (cutting oils, chlorinated hydrocarbons, and coal tars)
*Occlusion of sebaceous glands: heavy clothing, cosmetics, and tropical climates
*In some families

18. Acne vulgaris, cont’d 2 types: Noninflammatory & inflammatory
Noninflammatory: Open & closed comedones
Open comedone: small follicular papule containing a central black keratin plug
Closed comedone: follicular papule without a visible central plug
…the keratin plug is trapped beneath the epidermal surface
…potential sources of follicular rupture and inflammation
Inflammatory type: erythematous papules, nodules, and pustules
…Severe variants (e.g., acne conglobata) result in sinus tract formation and dermal scarring

19. Acne vulgaris, pathogenesis
1-Formation of keratin plug that blocks outflow of sebum to the skin surface 2-hypertrophy of sebaceous glands during puberty under the influence of androgens 3-lipase-synthesizing bacteria (Propionibacterium acnes) colonizing the upper and midportion of the hair follicle, converting lipids within sebum to proinflammatory fatty acids 4-Secondary inflammation of the involved follicle
*Elimination of P. acnes is the rationale for administration of antibiotics to individuals with inflammatory acne.
*The synthetic vitamin A derivative13-cis-retinoic acid (isotretinoin) brings about remarkable improvement in some cases of severe acne through its strong antisebaceous action

20. Thank You